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Free access

Andrew M. Hersh, A. Daniel Davidar, Carly Weber-Levine, Divyaansh Raj, Safwan Alomari, Brendan F. Judy, and Nicholas Theodore

Significant advancements in the treatment of spinal cord injury (SCI) were developed in the setting of military conflicts, partly due to the large numbers of injuries sustained by service members. No effective SCI treatment options existed into the early 20th century, and soldiers who sustained these injuries were usually considered untreatable. Extensive progress was made in SCI treatment during and after World War II, as physical therapy was increasingly encouraged for patients with SCI, multidisciplinary teams oversaw care, pathophysiology was better understood, and strategies were devised to prevent wound infection and pressure sores. Recent conflicts in Iraq and Afghanistan have caused a substantial rise in the proportion of SCIs among causes of casualties and wounds, largely due to new forms of war and weapons, such as improvised explosive devices. Modern military SCIs resulting from blast mechanisms are substantively different from traumatic SCIs sustained by civilians. The treatment paradigms developed over the past 100 years have increased survival rates and outcomes of soldiers with SCI. In this paper, the authors review the role of military conflicts in the development of therapeutic interventions for SCI and discuss how these interventions have improved outcomes for soldiers and civilians alike.

Open access

Amanda N. Sacino, Joshua Materi, A. Daniel Davidar, Brendan Judy, Ann Liu, Brian Hwang, and Nicholas Theodore

BACKGROUND

Placing screws in the high cervical spine can be challenging because of the vital anatomical structures located in that region. Precision and accuracy with screw placement is needed. The use of robotics in the cervical spine has been described before; however, here the authors describe the use of a new robotic setup.

OBSERVATIONS

The authors describe 2 cases of robot-assisted placement of C2 pars screws and C1–2 transarticular screws. The operative plans for each patient were as follows: placement of C2 pars screws with C2–4 fusion for hangman’s fracture and placement of C1–2 transarticular screws for degenerative disease. Intraoperative computed tomography (CT) was used to plan and navigate the screws. Postoperative CT showed excellent placement of hardware. Both patients presented for initial postoperative clinic visits with no recurrence of prior symptoms.

LESSONS

Intraoperative robotic assistance with instrumentation of the high cervical spine, particularly C2 pars and C1–2 transarticular screws, may ensure proper screw placement and help avoid injury.

Restricted access

Carly Weber-Levine, Brendan F. Judy, Andrew M. Hersh, Tolulope Awosika, Yohannes Tsehay, Timothy Kim, Alejandro Chara, and Nicholas Theodore

OBJECTIVE

The authors systematically reviewed current evidence for the utility of mean arterial pressure (MAP), intraspinal pressure (ISP), and spinal cord perfusion pressure (SCPP) as predictors of outcomes after traumatic spinal cord injury (SCI).

METHODS

PubMed, Cochrane Reviews Library, EMBASE, and Scopus databases were queried in December 2020. Two independent reviewers screened articles using Covidence software. Disagreements were resolved by a third reviewer. The inclusion criteria for articles were 1) available in English; 2) full text; 3) clinical studies on traumatic SCI interventions; 4) involved only human participants; and 5) focused on MAP, ISP, or SCPP. Exclusion criteria were 1) only available in non-English languages; 2) focused only on the brain; 3) described spinal diseases other than SCI; 4) interventions altering parameters other than MAP, ISP, or SCPP; and 5) animal studies. Studies were analyzed qualitatively and grouped into two categories: interventions increasing MAP or interventions decreasing ISP. The Scottish Intercollegiate Guidelines Network level of evidence was used to assess bias and the Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate confidence in the anticipated effects of each outcome.

RESULTS

A total of 2540 unique articles were identified, of which 72 proceeded to full-text review and 24 were included in analysis. One additional study was included retrospectively. Articles that went through full-text review were excluded if they were a review paper (n = 12), not a full article (n = 12), a duplicate paper (n = 9), not a human study (n = 3), not in English (n = 3), not pertaining to traumatic SCI (n = 3), an improper intervention (n = 3), without intervention (n = 2), and without analysis of intervention (n = 1). Although maintaining optimal MAP levels is the current recommendation for SCI management, the published literature supports maintenance of SCPP as a stronger indicator of favorable outcomes. Studies also suggest that laminectomy and durotomy may provide better outcomes than laminectomy alone, although higher-level studies are needed. Current evidence is inconclusive on the effectiveness of CSF drainage for reducing ISP.

CONCLUSIONS

This review demonstrates the importance of assessing how different interventions may vary in their ability to optimize SCPP.

Free access

Sophia A. Doerr, Carly Weber-Levine, Andrew M. Hersh, Tolulope Awosika, Brendan Judy, Yike Jin, Divyaansh Raj, Ann Liu, Daniel Lubelski, Craig K. Jones, Haris I. Sair, and Nicholas Theodore

OBJECTIVE

Damage to the thoracolumbar spine can confer significant morbidity and mortality. The Thoracolumbar Injury Classification and Severity Score (TLICS) is used to categorize injuries and determine patients at risk of spinal instability for whom surgical intervention is warranted. However, calculating this score can constitute a bottleneck in triaging and treating patients, as it relies on multiple imaging studies and a neurological examination. Therefore, the authors sought to develop and validate a deep learning model that can automatically categorize vertebral morphology and determine posterior ligamentous complex (PLC) integrity, two critical features of TLICS, using only CT scans.

METHODS

All patients who underwent neurosurgical consultation for traumatic spine injury or degenerative pathology resulting in spine injury at a single tertiary center from January 2018 to December 2019 were retrospectively evaluated for inclusion. The morphology of injury and integrity of the PLC were categorized on CT scans. A state-of-the-art object detection region-based convolutional neural network (R-CNN), Faster R-CNN, was leveraged to predict both vertebral locations and the corresponding TLICS. The network was trained with patient CT scans, manually labeled vertebral bounding boxes, TLICS morphology, and PLC annotations, thus allowing the model to output the location of vertebrae, categorize their morphology, and determine the status of PLC integrity.

RESULTS

A total of 111 patients were included (mean ± SD age 62 ± 20 years) with a total of 129 separate injury classifications. Vertebral localization and PLC integrity classification achieved Dice scores of 0.92 and 0.88, respectively. Binary classification between noninjured and injured morphological scores demonstrated 95.1% accuracy. TLICS morphology accuracy, the true positive rate, and positive injury mismatch classification rate were 86.3%, 76.2%, and 22.7%, respectively. Classification accuracy between no injury and suspected PLC injury was 86.8%, while true positive, false negative, and false positive rates were 90.0%, 10.0%, and 21.8%, respectively.

CONCLUSIONS

In this study, the authors demonstrate a novel deep learning method to automatically predict injury morphology and PLC disruption with high accuracy. This model may streamline and improve diagnostic decision support for patients with thoracolumbar spinal trauma.

Open access

Brendan F. Judy, Hector Soriano-Baron, Yike Jin, Hesham M. Zakaria, Srujan Kopparapu, Mir Hussain, Connor Pratt, and Nicholas Theodore

BACKGROUND

Navigation and robotics are important tools in the spine surgeon’s armamentarium and use of these tools requires placement of a reference frame. The posterior superior iliac spine (PSIS) is a commonly used site for reference frame placement, due to its location away from the surgical corridor and its ability to provide solid fixation. Placement of a reference frame requires not only familiarity with proper technique, but also command of the relevant anatomy.

OBSERVATIONS

Cadaveric analysis demonstrates a significant difference in PSIS location in males versus females, and additionally provides average thickness for accurate placement.

LESSONS

In this technical note, the authors describe the precise technique for PSIS frame placement in addition to relevant anatomy and offer solutions to commonly encountered problems.

Restricted access

Srujan Kopparapu, Gordon Mao, Brendan F. Judy, and Nicholas Theodore

Determination of the optimal approach to traumatic atlas fractures with or without transverse atlantal ligament (TAL) injury requires a nuanced understanding of the biomechanics of the atlantoaxial complex. The "rule of Spence" (ROS) was created in 1970 in a landmark effort to streamline management of burst-type atlas fractures. The ROS states that radiographic evidence of lateral mass displacement (LMD) (i.e., the distance that the C1 lateral masses extend beyond the C2 superior articular processes) greater than 6.9 mm may indicate both a torn TAL and need for surgical management. Since then, the ROS has become ubiquitous in the spine literature about atlas injuries. However, in the decades since the original paper by Spence et al., modern research efforts and imaging advancements have revealed that the ROS is inaccurate on both fronts: it neither accurately predicts a TAL injury nor does it inform surgical decision-making. The purpose of this review was to delineate the history of the ROS, demonstrate its limitations, present findings in the existing literature on ROS and LMD thresholds, and discuss the current landscape of management techniques for TAL injuries, including parameters such as the atlantodental interval and type of injury according to the Dickman classification system and AO Spine upper cervical injury classification system. The ROS was revolutionary for initially investigating and later propelling the biomechanical and clinical understanding of atlas fractures and TAL injuries; however, it is time to retire its legacy as a rule.

Restricted access

Yike Jin, Ann Liu, Jessica R. Overbey, Ravi Medikonda, James Feghali, Sonya Krishnan, Wataru Ishida, Sutipat Pairojboriboon, Ziya L. Gokaslan, Jean-Paul Wolinsky, Nicholas Theodore, Ali Bydon, Daniel M. Sciubba, Timothy F. Witham, and Sheng-Fu L. Lo

OBJECTIVE

Treatment of primary spinal infection includes medical management with or without surgical intervention. The objective of this study was to identify risk factors for the eventual need for surgery in patients with primary spinal infection on initial presentation.

METHODS

From January 2010 to July 2019, 275 patients presented with primary spinal infection. Demographic, infectious, imaging, laboratory, treatment, and outcome data were retrospectively reviewed and collected. Thirty-three patients were excluded due to insufficient follow-up (≤ 90 days) or death prior to surgery.

RESULTS

The mean age of the 242 patients was 58.8 ± 13.6 years. The majority of the patients were male (n = 130, 53.7%), White (n = 150, 62.0%), and never smokers (n = 132, 54.5%). Fifty-four patients (22.3%) were intravenous drug users. One hundred fifty-four patients (63.6%) ultimately required surgery while 88 (36.4%) never needed surgery during the duration of follow-up. There was no significant difference in age, gender, race, BMI, or comorbidities between the surgery and no-surgery groups. On univariate analysis, the presence of an epidural abscess (55.7% in the no-surgery group vs 82.5% in the surgery group, p < 0.0001), the median spinal levels involved (2 [interquartile range (IQR) 2–3] in the no-surgery group vs 3 [IQR 2–5] in the surgery group, p < 0.0001), and active bacteremia (20.5% in the no-surgery vs 35.1% in the surgery group, p = 0.02) were significantly different. The cultured organism and initial laboratory values (erythrocyte sedimentation rate, C-reactive protein, white blood cell count, creatinine, and albumin) were not significantly different between the groups. On multivariable analysis, the final model included epidural abscess, cervical or thoracic spine involvement, and number of involved levels. After adjusting for other variables, epidural abscess (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.64–5.63), cervical or thoracic spine involvement (OR 2.03, 95% CI 1.15–3.61), and increasing number of involved levels (OR 1.16, 95% CI 1.01–1.35) were associated with greater odds of surgery. Fifty-two surgical patients (33.8%) underwent decompression alone while 102 (66.2%) underwent decompression with fusion. Of those who underwent decompression alone, 2 (3.8%) of 52 required subsequent fusion due to kyphosis. No patient required hardware removal due to persistent infection.

CONCLUSIONS

At time of initial presentation of primary spinal infection, the presence of epidural abscess, cervical or thoracic spine involvement, as well as an increasing number of involved spinal levels were potential risk factors for the eventual need for surgery in this study. Additional studies are needed to assess for risk factors for surgery and antibiotic treatment failure.

Free access

Daniel Lubelski and Nicholas Theodore

Free access

Nicholas Theodore, Lola B. Chambless, Roger Hartl, Corinna C. Zygourakis, Bowen Jiang, and Themistocles S. Protopsaltis

Free access

Zach Pennington, Brendan F. Judy, Hesham M. Zakaria, Nikita Lakomkin, Anthony L. Mikula, Benjamin D. Elder, and Nicholas Theodore

OBJECTIVE

Spine robots have seen increased utilization over the past half decade with the introduction of multiple new systems. Market research expects this expansion to continue over the next half decade at an annual rate of 20%. However, because of the novelty of these devices, there is limited literature on their learning curves and how they should be integrated into residency curricula. With the present review, the authors aimed to address these two points.

METHODS

A systematic review of the published English-language literature on PubMed, Ovid, Scopus, and Web of Science was conducted to identify studies describing the learning curve in spine robotics. Included articles described clinical results in patients using one of the following endpoints: operative time, screw placement time, fluoroscopy usage, and instrumentation accuracy. Systems examined included the Mazor series, the ExcelsiusGPS, and the TiRobot. Learning curves were reported in a qualitative synthesis, given as the mean improvement in the endpoint per case performed or screw placed where possible. All studies were level IV case series with a high risk of reporting bias.

RESULTS

Of 1579 unique articles, 97 underwent full-text review and 21 met the inclusion and exclusion criteria; 62 articles were excluded for not presenting primary data for one of the above-described endpoints. Of the 21 articles, 18 noted the presence of a learning curve in spine robots, which ranged from 3 to 30 cases or 15 to 62 screws. Only 12 articles performed regressions of one of the endpoints (most commonly operative time) as a function of screws placed or cases performed. Among these, increasing experience was associated with a 0.24- to 4.6-minute decrease in operative time per case performed. All but one series described the experience of attending surgeons, not residents.

CONCLUSIONS

Most studies of learning curves with spine robots have found them to be present, with the most common threshold being 20 to 30 cases performed. Unfortunately, all available evidence is level IV data, limited to case series. Given the ability of residency to allow trainees to safely perform these cases under the supervision of experienced senior surgeons, it is argued that a curriculum should be developed for senior-level residents specializing in spine comprising a minimum of 30 performed cases.